[Column] What makes telemedicine controversial?

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- Choi’s View on Healthcare Innovation

Whether Korea should allow telemedicine has been controversial several times in the past administrations. Again, the current government’s plan to introduce telemedicine is facing vehement opposition from physicians. It is also rare for a country to enact a law to ban telehealth. What makes this issue repeatedly controversial? I would like to share how to solve this problem and what kind of misunderstandings and fundamental obstacles we should tackle.

Choi Yoon-sup

First, we should distinguish telemedicine from virtual visits. Even experts use the two terms interchangeably and find it difficult to define them. Telemedicine is a broad concept that includes various types of medical care, depending on services offered for patients. Virtual visits are one of the many kinds of telemedicine.

Virtual visits in the medical field are associated with “video examination,” but the term includes other types of services. Through virtual visits, patients can receive secondary medical opinions via sending medical records, medical images, and pathologic pictures. They can also receive a doctor’s advice by measuring an electrocardiogram or taking photographs of skin with a smartphone app or a medical device.

There are also services that are not virtual visits but included in telehealth. One of such services is “Remote Patient Monitoring (RPM),” by which a hospital can monitor data generated continuously by wearable devices, Internet-of-Things censors, or implantable medical devices. The evidence is emerging that RPM has a significant effect on improving the health of patients with chronic diseases. The RPM has begun to get insurance benefits in the U.S. this year.

Some in the local medical community is calling for the government to legalize RPM. The Korean Heart Rhythm Society is demanding the authorities allow RPM of implantable cardioverter-defibrillators (ICD). Local patients with arrhythmia use the ICDs with their RPM function turned off.

Second, we should understand that allowing telemedicine is unlikely to boost the healthcare industry. The government has misunderstandings about this issue.

In Korea, healthcare is a low-profit industry. Due to the nation’s single national health insurance system and medical institutions’ obligatory subscription of the health insurance policy, the government sets a price at every medical service. And the prices are significantly low, as maintained by the medical community. Hospitals’ profitability deteriorates because of such a price structure, and many hospitals suffer losses.

Under President Moon Jae-in’s push to expand health insurance coverage for low-income households, medical institutions’ low profitability will worsen further. Telemedicine is not an exception here.

When we talk about the medical industry’s profitability, we cannot help but mention the possibility of allowing for-profit hospitals – another social issue in Korea. Establishing a for-profit hospital in the country is illegal. Companies do not pursue something that is not profitable. Sadly, medical service providers don’t make money in Korea.

Besides, there is a rare demand for telehealth in Korea where seeing a doctor is easy. Here, if you get sick, you can see a specialist in a neighborhood clinic. The explosive growth of telemedicine in the U.S. is attributed to inadequate access to medical care.

It takes about two or three weeks for an average American to see a doctor after making a reservation at a primary hospital. According to some statistics last year, it took more than 100 days, in the worst case, for a person in Boston to meet a physician. Under such circumstance, telemedicine is an attractive option. However, it is not in Korea.

There is hardly a need for telehealth in Korea. However, “no need for telemedicine” does not mean we should “ban it.” Despite low profitability and weak demand, telemedicine’s various services could provide high medical value for patients.

Third, for telemedicine to be valuable to patients living in remote places, we should also discuss the delivery issue of medical and pharmaceutical products. In remote villages, not only hospitals but pharmacies are in shortage. Even if a patient receives medical examinations and prescriptions via telehealth, the patient should find a pharmacy outside the home to purchase the drug.

However, delivering medicine is prohibited in Korea. This is another issue opposed by local pharmacists. There is no such regulation in the U.S. and China. Amazon and Alibaba recently entered the drug delivery market.

The broken healthcare delivery system is a bigger problem in Korea. A Korean patient with a cold is allowed to visit an emergency room at a general hospital. Small clinics have to compete against large university hospitals. Large hospitals are always overcrowded because they should cover patients with mild cases. Urgent patients at ER could be put in danger while physicians take care of patients with mild symptoms.

In this situation, introducing telemedicine could confuse the already broken medical delivery system. Without fixing the fundamental problem in the medical delivery system, telehealth might cause side effects.

It all comes down to the issue of trust, after all. It is the most difficult and the most fundamental problem. The government does not trust physicians, and physicians regard the government with suspicion. Sometimes, the government failed to reflect the voices of the medical community in executing policies. In other times, the medical community was unable to come up with an internal consensus and effectively communicate with the government.

Now, physicians oppose the government’s plan no matter what and the government seems to be missing the point of the medical industry’s fundamental problems and needs.

To sum up, telemedicine is a complicated issue. There is no consensus on its definition or the scope of the discussion. Without understanding the expected results of introducing telehealth or solving the fundamental problems in the medical industry, people are talking about controversies on the surface only. During the process, distrust among stakeholders is only growing.

What’s most disappointing is that telemedicine has become a political issue about which we cannot have a proper debate. We cannot discuss why it is allowed overseas and not in Korea; what kind of fundamental characteristics there are in the Korean medical system; if there is any absurdity in the healthcare system that should be solved before introducing telemedicine; how telehealth is medically grounded and how it can help patients.

Medicine is the foundation of a society responsible for the public health. It is also a welfare industry and a science judged by logic and reasons. This is why medicine is so unique and complex, involving diverse interests. Where should we start to find a solution for telemedicine? Regrettably, finding the clue will not be easy, unless we reach a social consensus and restore the trust of stakeholders.